Knee ROM Research Articles

Botulinum toxin a does not decrease calf pain or improve ROM during limb lengthening: a randomized trial.

During lower limb lengthening, distraction-induced muscle pain and surrounding joint contractures are frustrating complications for which few effective treatments are available. We evaluated Botulinum Toxin Type A (BtX-A) injection in the calf muscles during human tibial distraction osteogenesis. We hypothesized that it may decrease calf pain and increase ROM of the surrounding joints by reducing muscle stiffness. Between April 2010 and January 2011, we evaluated 36 patients undergoing bilateral tibia lengthening who met prespecified inclusion criteria. All patients underwent stature lengthening with lengthening over a nail or lengthening and then nailing. BtX-A (200IU) was injected at the calf muscle only in one leg for each patient and the same amount of sterile normal saline was injected into the other leg as a control. Selection of the leg receiving the toxin was randomized. Clinical evaluation included a VAS score for calf pain and measurement of ROM of the knees and ankles and calf circumference, with evaluations performed in a double-blinded manner. Side-to-side differences were analyzed until the end of consolidation phase. Minimum followup was 24months (mean, 30months; range, 24-39months). The distraction rate and the final length gain were similar in the treated and control limbs. A priori power analysis suggested that 34 legs were required to achieve statistical significance of 0.05 with 80% of power to detect a 50% difference in treatment effect between treatment and control groups. There were no differences in calf pain, knee and ankle ROM, and maximal calf circumferences between the two legs at each time point. Local injection of 200IU BtX-A at the human calf muscle does not appear to reduce calf pain or help enhance ROM of the knee and ankle during tibial lengthening. However, the small sample size provided sufficient power to detect only relatively large clinical effects; future, larger trials will be needed to determine whether smaller differences are present. Level II, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

Two-stage Approach to Primary TKA in Infected Arthritic Knees Using Intraoperatively Molded Articulating Cement Spacers

The treatment of knee arthritis with coexistent bone or joint sepsis is challenging. Despite the condition causing considerable morbidity, there is no generally agreed-upon approach to its treatment. We used aggressive débridement of the knee and implantation of intraoperatively molded articulating antibiotic cement spacers with 4g vancomycin and 2g streptomycin per bag of cement for patients with unknown organisms as a first stage. When the infecting organism was known, organism-specific antibiotics were used. For fungal infections, 400mg amphotericin B was added per bag of cement. This was followed by TKA as a second stage once soft tissues had healed 2 to 29months later, (mean, 6months) and return of laboratory parameters to within a normal range. One patient underwent two débridement and spacer procedures for suspected persistent infection. To determine whether this approach resulted in adequate control of infection and satisfactory scores for pain and function, we retrospectively reviewed 15 patients who presented with infected arthritic knees between 2001 and 2009; all patients with infected arthritic knees were treated with this same technique during this period. We assessed knee ROM, Knee Society scores, WOMAC scores, and VAS scores preoperatively and during followup. Followup was at a mean of 4years (range, 2-7years); No patient was lost to followup before 2years. Two of the 15 patients were comfortable with the spacers and declined a more definitive reconstruction, and no patient had a recurrent infection after TKA. Before spacer placement, the mean ROM was 103.° (range, 60°-150°), with the spacers in place it decreased to a mean 87° (range, 60°-135°), and after TKA it improved to a mean of 115° (range, 75°-150°). The mean Knee Society Knee and Function scores progressed from 41 and 43 preoperatively to 85 and 83 at latest followup, respectively. The WOMAC scores improved from 51 initially to 18 after TKA. The mean VAS scores improved from 66 preoperatively to 18 after the TKA. In this small proof-of-concept series, we found that joint débridement and use of intraoperatively molded articulating antibiotic cement spacers as part of a staged approach to treat the infected arthritic knee before TKA resulted in infection control in all patients at a minimum of 2years' followup, reduction of knee pain, and restoration of knee function. We suggest that larger, comparative series be performed to further validate these results.

Does Chondrocalcinosis Affect Knee Society Scores and Range of Motion After TKA?

Chondrocalcinosis is manifested by crystalline deposits of calcium commonly found during primary TKA for osteoarthritis. Its frequency among patients undergoing TKA is poorly defined, as is its influence on pain or function after TKA. The purposes of this study are to (1) determine the prevalence of chondrocalcinosis in patients undergoing TKA for osteoarthritis; (2) evaluate the effect of chondrocalcinosis on ROM and The Knee Society scores; (3) determine if patients with chondrocalcinosis and severe synovitis who underwent synovectomy are at risk for lower postoperative Knee Society scores and less ROM; and (4) assess if chondrocalcinosis is associated with increased rates of revision surgery. We retrospectively reviewed the medical records of 1500 primary TKAs performed by one surgeon. The minimum followup for patients was 24months (average, 57months; range, 24-120months). There were 511 men and 934 women with an average age of 70years. Fifty-five patients underwent bilateral knee replacements. Crystal deposition was graded prospectively during surgery using a subjective visual scale. A thorough synovectomy was performed on patients with severe synovitis and apparent crystalline deposition suggestive of calcium pyrophosphate dihydrate (CPPD) deposition (n=50). The Knee Society scores, ROM, and revision rates were compared between patients with visible chondrocalcinosis with those without and between patients with mild chondrocalcinosis with those with severe chondrocalcinosis. Chondrocalcinosis was found in 173 male patients (34%) undergoing TKAs during this period compared with 224 female patients (24%) (p<0.001). The Knee Society scores for knee rating and function were similar in patients with or without chondrocalcinosis undergoing TKA. However, patients with visible CPPD deposition who underwent synovectomy for proliferative synovitis had diminished final ROM and Knee Society knee rating scores (107(o) versus 115(o) knee flexion, p<0.001 and 87 versus 94 points, p=0.001). We cannot determine whether this result is because of the synovectomy or severity of the disease, and therefore we cannot recommend a synovectomy at this time. Revision rates were no different among patients with chondrocalcinosis compared with those without it (3.6% versus 2.2%, p=0.2). Chondrocalcinosis is common among patients undergoing TKA for osteoarthritis. The presence of CPPD deposition does not appear to affect the ROM and Knee Society scores of patients with CPPD but without severe synovitis. However, patients with severe synovitis and visible CPPD who underwent thorough synovectomy may be at risk for having decreased postoperative ROM and pain develop. Level III, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Symmetrical kinematics does not imply symmetrical kinetics in people with transtibial amputation using cycling model.

People with amputation move asymmetrically with regard to kinematics (joint angles) and kinetics (joint forces and moments). Clinicians have traditionally sought to minimize kinematic asymmetries, assuming kinetic asymmetries would also be minimized. A cycling model evaluated locomotor asymmetries. Eight individuals with unilateral transtibial amputation pedaled with 172 mm-length crank arms on both sides (control condition) and with the crank arm length shortened to 162 mm on the amputated side (CRANK condition). Pedaling kinetics and limb kinematics were recorded. Joint kinetics, joint angles (mean and range of motion [ROM]), and pedaling asymmetries were calculated from force pedals and with a motion capture system. A one-way analysis of variance with tukey post hoc compared kinetics and kinematics across limbs. Statistical significance was set to p </= 0.05. The CRANK condition reduced hip and knee ROM in the amputated limb compared with the control condition. There were no differences in joint kinematics between the contralateral and amputated limbs during the CRANK condition. Pedaling asymmetries did not differ and were 23.0% +/= 9.8% and 23.2% +/= 12% for the control and CRANK conditions, respectively. Our results suggest that minimizing kinematic asymmetries does not relate to kinetic asymmetries as clinically assumed. We propose that future research should concentrate on defining acceptable asymmetry.

To Put Back in the Body or to Drop in the Bucket- Outcome after Using an Extruded Devitalized Segment of Bone in an Open Distal Femoral Fracture

A segmental bone defect caused by an open fracture is a daunting problem to deal with and the traditional treatment options that are currently practiced to treat such conditions include allo or autologous bone graft, distraction osteogenesis and membrane induction. Infrequently the course of treatment is complicated by non-union and infection, thus requiring multiple staged procedures that may affect the functional outcome. We present a case of a 25 year old gentleman who had sustained an isolated open type III A comminuted distal femur fracture with a part of the diaphyseal distal femur extruding from the body with no soft tissue attached. His plain radiograph showed comminuted distal femur AO C3 fracture. Following debridement, the extruding diaphyseal fragment was washed and cleaned with normal saline and retained inside the body. The limb was stabilized with an external fixator and 48 hours later he was taken for a second debridement wherein a stable internal fixation was done retaining the extruded fragment. Post operatively he recovered well without wound complications or any deep or superficial infection. The follow up radiographs showed that the bone coalesced with an uneventful union and in next 3 years the knee ROM was 0-130 degrees. His lower extremity functional score was (LEFS) 74. This case is to highlight the importance of judicious insight at times when debridement is the matter of concern, taking into consideration that all reconstructive options are available. The outcome of other staged reconstructive procedures to bridge such bone loss is far more tedious and sure to have a far less efficacious outcome than what has been described here. This report also described about other literature about the option available for such condition.

정상인 보행에서 무릎관절의 유도된 강직에 따른 신체 보상 특성

The purposes of this study were investigated physical compensation for gait on induced knee stiffness in normal subjects. Ten subjects were participated in the experiment(age: <TEX>$26.0{\pm}6.3$</TEX> yrs, height: <TEX>$175.5{\pm}5.3$</TEX> cm, weight: <TEX>$69.1{\pm}6.1$</TEX> kg). The study method adopted 3D analysis with five cameras and ground reaction force with two force-plate. Induced knee stiffness level were classified as gait pattern on ROM of knee(free level, <TEX>$30^{\circ}$</TEX> restriction level, fix level). The results were as follows; In angular displacement of hip joint, left hip joint was the more extended in mid-stance on induced right knee stiffness. In angular displacement of knee joint, there was no physical compensation on induced right knee stiffness, but free knee level gait was more flexed in swing phase of right knee joint. In angular displacement of ankle joint, right ankle joint was the more dorsiflexed on induced right knee stiffness, and <TEX>$30^{\circ}$</TEX> restriction level and fix level gait were less plantarflexed in TO2. In trunk tilt, free and <TEX>$30^{\circ}$</TEX> restriction level gait was more backward tilt on induced right knee stiffness. In ROM of each joint, right knee joint was more larger and trunk tilt was more lower on induced right knee stiffness. In GRF, Fx was more bigger lateral force in free and <TEX>$30^{\circ}$</TEX> restriction level gait, and was more bigger medial force in fix level gait. Fy was more bigger propulsion force in free level gait, and was was more bigger braking force in <TEX>$30^{\circ}$</TEX> restriction level gait. Left braking force in <TEX>$30^{\circ}$</TEX> restriction level gait was more bigger. Fz was no significant.

Positive and negative work during walking in children with cerebral palsy

Introduction:Walking velocity (WV) is known to influence different gait parameters [1,2]. Muscle length (ML) and especially lengthening velocity (MLV) increase with WV. Spasticity on the otherhand is associatedwith reducedMLandMLV [1]. Spasticmuscles show an increased coupling between EMG activity and MLV [3]. Therefore, we described the effect of walking speed on spastic hamstrings, with a focus on ML, MLV and EMG. Patients/materials and methods: 49 Children with CP (9.8±3 years)with aModified Ashworth Score≥1.5 for the hamstrings and 14 TD children (10.5±2.4 years) received a 3D lower limb gait analysis, including kinematics, kinetics (8 camera Vicon system), EMG of 8 muscles bilateral (Cometa, Wave EMG) and a clinical examination. They were instructed to walk at self-selected speed, faster and as fast as possible without running. To compare both groups, a linear regression model was created which resulted in two nondimensional gait velocities (v1, v2), used to compare a large set of parameters. Difference scores (DS) between both velocities were calculated. Statistical analysis was done using the Mann-Whitney U test. Results: During stance at both velocities, the CP group showed more knee flexion at IC (p<0.001) and duringmid stance (p<0.01), increasing with WV. The knee ROM during shock absorption was higher in the TD group. EMG activity in early stance phase was significantly higher in the CP group at v2 (p<0.05), corresponding to an increasing maximum hip moment (H1) in CP children, which was not seen in the TD group (DS: p=0.001). During swing, the maximum angular extension velocity was significantly higher in the TD group compared to the CP group at v1 and v2 (p<0.005), increasing with WV. Maximum MLV showed similar results, with a significant DS (p<0.005) indicating a higher increase in the TD group. No difference was seen in the maximum ML between both groups,while total range ofMLwas significantly higher in TD group at both speeds, with increasing length range at higher WV. EMG activity in swing showed significantly higher activity at v1 for the CP group, but not at v2. Discussion and conclusions: The effect of WV on knee kinematics at IC and mid stance are in accordance to Schwartz [2] and similar for TD and CP children. The increasing hamstrings activity in CP in early stance may be explained by the biomechanical demands (hip moment). In contrast with TD children who mainly use the gastrocnemius at late stance (push-off) to increase WV. In swing, TD children are capable of increasing their angular velocity and MLV more than children with CP. Van der Krogt [1] reported similar results. This confirms the fact that, although CP children are able to increase their MLV, they prefer to stay under their spastic threshold velocity during self-selectedWV. The TD group increases their EMG swing phase activity similar as CP children. This can be explained by a higher angular velocity due to the increased WV, demanding more eccentric contraction of the hamstrings to slow down knee extension motion. The difference in influence of WV on spastic hamstrings compared to TD children seems to be most pronounced on MLV, and less on EMG activity. Compared to the influence of WV on the spastic gastrocnemius, the latter showed an increase in EMG activity in swing, which was not seen in the TD group [4].

Interaction between walking speed and spasticity in children with spastic hamstrings

Introduction:Walking velocity (WV) is known to influence different gait parameters [1,2]. Muscle length (ML) and especially lengthening velocity (MLV) increase with WV. Spasticity on the otherhand is associatedwith reducedMLandMLV [1]. Spasticmuscles show an increased coupling between EMG activity and MLV [3]. Therefore, we described the effect of walking speed on spastic hamstrings, with a focus on ML, MLV and EMG. Patients/materials and methods: 49 Children with CP (9.8±3 years)with aModified Ashworth Score≥1.5 for the hamstrings and 14 TD children (10.5±2.4 years) received a 3D lower limb gait analysis, including kinematics, kinetics (8 camera Vicon system), EMG of 8 muscles bilateral (Cometa, Wave EMG) and a clinical examination. They were instructed to walk at self-selected speed, faster and as fast as possible without running. To compare both groups, a linear regression model was created which resulted in two nondimensional gait velocities (v1, v2), used to compare a large set of parameters. Difference scores (DS) between both velocities were calculated. Statistical analysis was done using the Mann-Whitney U test. Results: During stance at both velocities, the CP group showed more knee flexion at IC (p<0.001) and duringmid stance (p<0.01), increasing with WV. The knee ROM during shock absorption was higher in the TD group. EMG activity in early stance phase was significantly higher in the CP group at v2 (p<0.05), corresponding to an increasing maximum hip moment (H1) in CP children, which was not seen in the TD group (DS: p=0.001). During swing, the maximum angular extension velocity was significantly higher in the TD group compared to the CP group at v1 and v2 (p<0.005), increasing with WV. Maximum MLV showed similar results, with a significant DS (p<0.005) indicating a higher increase in the TD group. No difference was seen in the maximum ML between both groups,while total range ofMLwas significantly higher in TD group at both speeds, with increasing length range at higher WV. EMG activity in swing showed significantly higher activity at v1 for the CP group, but not at v2. Discussion and conclusions: The effect of WV on knee kinematics at IC and mid stance are in accordance to Schwartz [2] and similar for TD and CP children. The increasing hamstrings activity in CP in early stance may be explained by the biomechanical demands (hip moment). In contrast with TD children who mainly use the gastrocnemius at late stance (push-off) to increase WV. In swing, TD children are capable of increasing their angular velocity and MLV more than children with CP. Van der Krogt [1] reported similar results. This confirms the fact that, although CP children are able to increase their MLV, they prefer to stay under their spastic threshold velocity during self-selectedWV. The TD group increases their EMG swing phase activity similar as CP children. This can be explained by a higher angular velocity due to the increased WV, demanding more eccentric contraction of the hamstrings to slow down knee extension motion. The difference in influence of WV on spastic hamstrings compared to TD children seems to be most pronounced on MLV, and less on EMG activity. Compared to the influence of WV on the spastic gastrocnemius, the latter showed an increase in EMG activity in swing, which was not seen in the TD group [4].

Which functional impairments are the main contributors to pelvic anterior tilt during gait in individuals with cerebral palsy?

While past investigations focused on describing pelvic motion patterns in the frontal and transversal plane, the sagittal plane “double bump” pattern commonly found in children with cerebral palsy was only rarely investigated, especially concerning the underlying pathology.375 ambulatory (GMFCS I–III) patients with bilateral spastic cerebral palsy were included in this study. Gait and clinical data (ROM, strength, spasticity) were classified in two different ways: (a) into two groups of normal and enhanced mean anterior pelvic tilt and (b) into two groups of moderate and excessive ROM in pelvic tilt.The results reveal that increased mean pelvic tilt is mainly associated with gait features of reduced hip extension and increased pelvic and trunk obliquity ROM but with increased knee ROM. In the clinical exam this corresponds to a smaller passive knee extension deficit and reduced knee flexor strength. It seems that flexors to extensors strength imbalance at the knee is a major feature why mean pelvic position is tilted anterior whereas maximum passive hip extension is of minor importance.Contrarily, excessive sagittal pelvic ROM is associated with increased knee flexion at initial contact and reduced knee ROM. Furthermore, Duncan-Ely- and Tardieu-tests show both increased values in this group with excessive pelvic range of motion indicating for spastic rectus femoris activation.The results of our study indicate that the two gait variables are influenced by different specific mechanisms which are now described for the first time. Since the pelvis plays a central role during gait, these findings should be considered when planning single event multilevel surgery in patients with cerebral palsy.

Bariatric Orthopaedics: Total Knee Arthroplasty in Super-obese Patients (BMI &gt; 50 kg/m2). Survivorship and Complications

Some studies have suggested that patients who are super obese (BMI > 50 kg/m(2)) may have poorer outcomes and more frequent complications when undergoing TKA compared with those who have lower BMI, however, the literature on this is scant. The purpose of this study was to compare a group of super-obese patients undergoing TKA with a matched group of patients with BMI less than 30 kg/m(2) in terms of (1) implant survivorship, (2) complications, (3) functional parameters, and (4) intraoperative variables (including operative time and estimated blood loss). One-hundred one knees in 95 patients (21 men, 74 women) who had a minimum BMI of 50 kg/m(2) and who had undergone a primary TKA at one of the four high-volume institutions were compared with a group of patients who had a BMI less than 30 kg/m(2) who were matched by age, gender, preoperative clinical scores, and mean followup. End points evaluated by chart review included implant survivorship, medical and surgical complications, functional parameters (The Knee Society outcome scores and ROM), and intraoperative variables at a mean followup of 62 months (range, 36-85 months). With the numbers available, there were no differences in aseptic implant survivorship (94% versus 98%, p = 0.28), however, medical and surgical complication rates (14% versus 5%, OR: 3.1, 95% CI=1.07-8.9; p = 0.037) were significantly higher in the super-obese patients compared with the nonobese matching group, respectively. Super-obese patients also achieved lower mean Knee Society functional scores (82 versus 90 points, p = 0.004) and smaller gains in flexion arc ROM (14° versus 21°, p = 0.009); they also lost more blood during surgery and experienced longer surgical anesthesia times compared with the matched group, respectively. With the numbers available, we could not identify what might have been modest differences in implant survivorship, however, complications were more frequent and functional outcomes were significantly lower in super-obese patients. Other studies similarly have found inferior outcomes in this challenging group of patients. Our data may be considered pilot data for future prospective studies with longer followup.

AB1425-HPR Effects of a yoga program on pain relief, reducing anxiety and extended range of motion of knee in rheumatoid arthritis patients

BackgroundRheumatoid Arthritis as a chronic systemic disease, is the most common cause of joints inflammation and deformity. Chronic pain, fatigue, decline in physical activity and joint range of motion limitation...

Surgical Technique: Tscherne-Johnson Extensile Approach for Tibial Plateau Fractures

BackgroundThe standard approach to lateral tibial plateau fractures involves elevation of the iliotibial band (IT) and anterior tibialis origin in continuity from Gerdy’s tubercle and metaphyseal flare. We describe an alternative approach to increase lateral plateau joint exposure and maintain iliotibial band insertion to Gerdy’s tubercle.Description of TechniqueThe approach entails a partial tenotomy of the anterior half of the IT band leaving the posterior IT band insertion attached to Gerdy’s tubercle. Fracture lines around Gerdy’s tubercle are completed or the tubercle was osteotomized and externally rotated and the joint overdistracted, allowing direct visualization of the joint depression. Joint elevation, grafting, and internal fixation are performed through this window.MethodsWe retrospectively reviewed 76 patients (two groups), Schatzker Types I to II and IV to VI fractures (66 patients), between 1989 and 2005, and 10 patients, with 10 bicondylar posterior plateau fractures, from 2002 to 2010. All patients were followed a minimum of 12 months (average, 3.9 years; range, 12 months to 10 years). Ten patients, with posterior plateau fractures, received anterolateral plateau intraarticular osteotomy for exposure of centroposterior and posterolateral articular depression.ResultsAverage knee ROM was 2° of flexion (range, −3° to 5°) to greater than 120° of flexion (range, 100°–145°). In 66 patients, average articular depression improved from 7.4 mm to 1 mm (range, 0–5 mm) and, in 10 posterior fractures, from 18 mm to 1 mm (range, 0–4.5 mm). Infection occurred in one of the 76 patients; acute débridement and intravenous antibiotics resulted in control of the infection.ConclusionsThis approach reliably increases direct visualization of the lateral plateau articular fractures and maintains IT band insertion. Articular osteotomy of the anterolateral plateau provides access to extensive posterior plateau fractures.Level of EvidenceLevel IV, retrospective study. See Guidelines for Authors for a complete description of levels of evidence.

Periarticular Injection in Knee Arthroplasty Improves Quadriceps Function

The postoperative analgesic potential of periarticular anesthetic infiltration (PAI) after TKA is unclear as are the complications of continuous femoral nerve block on quadriceps function. We asked (1) whether PAI provides equal or improved postoperative pain control in comparison to a femoral nerve block in patients who have undergone TKA; and (2) if so, whether PAI improves early postoperative quadriceps control and facilitates rehabilitation. We randomized 60 patients to receive either PAI or femoral nerve block. During the first 5 days after TKA, we compared narcotic consumption, pain control, quadriceps function, walking distance, knee ROM, capacity to perform a straight leg raise, and active knee extension. Medication-related side effects, complications, operating room time, and hospitalization duration were compared. Opioid consumption was lower in the PAI group during the first 8 postoperative hours (12.5 mg versus 18.7 mg morphine), as was reported pain at rest (1.7 versus 3.5 on a 10-point VAS). Thereafter, narcotic consumption and reported pain were similar up to 120 hours. More subjects in the femoral nerve block group experienced quadriceps motor block (37% versus 0% in the PAI group). On Days 1 to 3, subjects in the PAI group experienced better capacity to perform the straight leg raise, active knee extension, and had longer walking distances. PAI provided pain control equivalent to that of a femoral nerve block while avoiding a motor block and its negative functional impacts. The data suggest it should be considered an alternative to a femoral nerve block. Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Rectus femoris transfer in multilevel surgery: Technical details and gait outcome assessment in cerebral palsy patients

In children with cerebral palsy the abnormal activity of the rectus femoris (RF) during the swing phase results in "stiff-knee gait". Transferring the RF to a knee flexor tendon improves this stiffness. The effect may be limited by adhesions from scar tissue or from angular deviations along the surgically created muscle tendon route. The goal of this study was to assess the effect on gait of a single event multilevel surgery protocol, and provide a detailed description of the transfer technique. Forty-eight RF transfers were studied in 26 children and adolescents 12 ± 3 years old after a follow up of 25 ± 10 months. Quantified gait analysis was performed pre- and postoperatively to calculate spatiotemporal variables, 3D kinematics, the Gait Deviation Index (GDI) and a knee stiffness score (Goldberg index). A standardized surgical procedure was followed: RF release, gracilis tendon preparation as well as the transfer and suture techniques are described. Step length improved. Gait velocity and cadence were not modified. Gait quality improved (+13 ± 11 GDI) with an inverse relationship between the preoperative GDI and its improvement. Improvement of the preoperative Goldberg index in 74% of the cases was due to modifications of knee ROM from toe-off to peak flexion (+7°), total knee ROM (+16°) and timing of peak knee flexion in percentage of swing (from 51 to 40% of swing). The surgical protocol presented here is discussed in relation to the results. IV, retrospective study.

Comparative Demographics, ROM, and Function After TKA in Chinese, Malays, and Indians

There is marked racial disparity in TKA use rates, demographics, and outcomes between white and Afro-Caribbean Americans. Comparative studies of ethnicity in patients undergoing TKAs have been mostly in American populations with an underrepresentation of Asian groups. It is unclear whether these disparities exist in Chinese, Malays, and Indians. We therefore determined whether (1) TKA use; (2) demographics and preoperative statuses; and (3) functional outcomes at 2 years after TKA differed among three ethnic groups, namely, Chinese, Malays, and Indians who underwent TKA. From our hospital joint registry we identified 5332 patients who had a primary TKA from 2004 to 2009. The cohort was stratified by race and subsequently compared for demographics, preoperative knee ROM, and deformity. At the second postoperative year we determined Knee Society scores, Oxford knee scores, and obtained SF-36 health questionnaires. Six percent more Chinese patients underwent TKAs compared with Malays or Indians. Malays were operated on at a younger age with a higher body mass index. Chinese patients had more severe preoperative varus deformity. There were no major differences in joint ROM in all races. For Knee Society, Oxford knee, and SF-36 scores, Chinese patients had consistently higher preoperative and postoperative scores. Malays presented with the lowest preoperative scores but had the greatest improvement in scores at followup with postoperative scores similar to Chinese counterparts. Indians had the lowest postoperative scores and worst improvement of all The variations in demographics, preoperative statuses, and subsequent postoperative outcomes between the races should be considered when comparing TKA outcome studies in Asian populations.

Surgical Technique: Computer-assisted Sliding Medial Condylar Osteotomy to Achieve Gap Balance in Varus Knees During TKA

Extensive posteromedial release to correct severe varus deformity during TKA may result in mediolateral or flexion instability and may require a constrained implant. We describe a technique combining computer navigation and medial condylar osteotomy in severe varus deformity to achieve a primary goal of ligament balance during TKA. The goal of this procedure was to achieve mediolateral gap balance in varus knees with rigid, recalcitrant medial contracture, with or without excessive lateral laxity, not amenable to extensive medial soft tissue releases. A sliding medial condylar osteotomy (SMCO) was performed under navigation guidance and the condylar block internally fixed using cancellous screws. We prospectively evaluated mediolateral laxity, Knee Society scores, and knee ROM after SMCO in 12 varus arthritic knees in 11 patients (five men, six women) undergoing TKA with a minimum followup of 2 years (mean, 2 years; range, 2-2.5 years). The degree of mediolateral knee laxity improved from Grade 2 (in four knees) and Grade 3 (in eight knees) preoperatively to Grade 1 (< 5 mm) in all knees at last followup. Mean Knee Society score improved from 30 (range, 10-54) to 92 (range, 86-100). Mean knee flexion improved from 106° (range, 90°-120°) to 112° (range, 100°-124°), and no knee had any extensor lag or residual flexion deformity (> 5°). Three knees had asymptomatic fibrous union at the osteotomy site. Computer-assisted SMCO in varus knees with recalcitrant medial contracture achieves improved mediolateral stability and knee function after TKA. Our technique uses navigation to accurately reposition the medial condylar block to equalize medial and lateral gaps, thereby ensuring a stable well-aligned knee without deploying constrained implants.

A Randomized Comparison of effectiveness of Clinical Exercises and Manual Therapy Procedures Versus Clinical Exercises alone in the Treatment of Osteoarthritis of Knee

Aim: This study is designed to compare the effectiveness of clinical exercises and manual therapy procedures with clinical exercises alone for reducing pain and improving physical function in OA knee patients. To know particularly the effectiveness of manual therapy procedures for the management of OA knee patients. Study design: Experimental study, Randomized Control Trial. Method: 40 patients of OA knee were recruited into two groups .Experimental Group (n=20) received Manual Therapy which included passive physiological and accessory movements (Maitland), muscle stretching and soft tissue mobilization along with clinical exercises as strengthening ,muscle stretching, range of motion exercises of knee joint and stationary bicycle. Control Group (n=20) received clinical exercises alone which included strengthening, muscle stretching, range of motion exercises of knee joint and stationary bicycle with detailed evaluation including WOMAC, ROM and all parameters of 6-minute walk test were taken as baseline as well as after 4 week of treatment. Results: Both the groups showed clinically and statistically significant improvement in WOMAC and 6- minute walk test at 4-weeks .WOMAC scores had improved by 52% in experimental group and by 41% in control group. Average 6- minute walk had improved about 10% in both the groups. Conclusion: There was significant improvement in both the groups; however the manual therapy and clinical exercises group was more effective in reducing pain and improving knee ROM for patients of Osteoarthritis of knee as compared to clinical exercises group.

The effect of muscle fatigue on the last stride before stepping down a curb

The stride before landing may be important during stepping down. The aim of this study was to analyze variability of the kinematics and muscle activity in the final stride before stepping down a curb, with and without ankle and knee muscle fatigue. Ten young participants walked at self-selected speed and stepped down a height difference (10-cm) in ongoing gait. Five trials were performed before and after a muscle fatigue protocol (one day: ankle muscle fatigue, another day: knee muscle fatigue). The analysis focused on the trailing leg during the last but one and the last step on the higher level. Kinematics and muscle activity were recorded. Fatigue increased variability of foot-step horizontal distance in the last step on the higher level of the trailing limb, as well as in the first steps on the lower level for both limbs. This appeared due to an increase in the range of motion of the knee joint after both fatigue protocols. Participants additionally showed an increased ankle and hip ROM and decreased knee ROM. Our results suggest a loss of control under fatigue reflected in a higher variability of trailing and leading limb-step horizontal distances, with compensatory changes to limit fatigue effects, such as a redistribution of movement over joints.

Clinical evaluation and rehabilitation prescription for knee motion loss

IntroductionRange-of-motion (ROM) loss of the knee is commonly treated in rehabilitation settings. Variables that contribute to ROM loss include trauma to the knee joint, surrounding soft tissue, or surgery. The skilled clinician identifies how abnormalities in specific anatomic structures contribute to motion loss and then formulates a logical treatment plan to target these structures. A thorough understanding of the arthrokinematic characteristics of the knee is necessary in order to treat knee ROM loss by guiding effective mobilization techniques. Methods describedAn evaluative algorithm is described for the clinical management of knee ROM loss. Methods to identify specific anatomical structures contributing to motion loss leading to the formulation of a logical and effective treatment plan that targets these structures are outlined. The rehabilitation prescription which specifies paramaters of treatment, such as frequency, duration, order, and total volume of interventions should be designed within the context of providing optimal mechanical signal to the healing tissue for remodeling and repair. PurposeThis paper describes evaluative strategies to identify how soft tissue structures contribute to ROM. Formulation of an optimal rehabilitation prescription is discussed.

Minimizing Dynamic Knee Spacer Complications in Infected Revision Arthroplasty

Deep infections are devastating complications of TKA often treated with component explantation, intravenous antibiotics, and antibiotic-impregnated cement spacers. Historically, the spacers have been static, which may limit patients' ROM and ability to walk. Several recent reports describe dynamic spacers, which may allow for improved ROM and make later reimplantation easier. However, because of several dynamic spacer problems noted at our institution, we wanted to assess their associated failures, reinfection rates, and functionality. We therefore asked whether there were differences between static and dynamic spacers in (1) reinfection rates, (2) complications directly related to the spacer, and (3) final patient functionality as measured by Knee Society objective scores and ROM. We retrospectively identified 111 patients (115 knees) with 34 dynamic spacers (30%) and 81 static spacers (70%). Reinfection rates, complications requiring additional surgery, and final Knee Society scores and ROM were collected for all patients. Reinfection rates were comparable between groups. In the dynamic spacer cohort, there were four complications; however, these could all be explained by surgical technical errors or patient weightbearing compliance. All patients with failed results eventually underwent successful two-stage exchange arthroplasty. Final Knee Society scores and ROM were also similar between groups. Reinfection rates, Knee Society scores, and ROM were comparable between the static and dynamic spacer groups. Meticulous surgical technique and proper patient selection should be used to avoid any complications with any spacers.